Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for an infant who has gastroesophageal reflux (GER). Which of the following actions should the nurse take to prevent regurgitation? (Select all that apply.)
A. Thicken the infant's formula with cereal.
Thicken the infant's formula with cereal: Thickening the infant's formula with cereal can help reduce the likelihood of regurgitation by increasing its viscosity and promoting better gastric emptying. This can help decrease the frequency and severity of gastroesophageal reflux episodes.
B. Avoid giving the infant citrus juices.
Avoid giving the infant citrus juices: Citrus juices are acidic and can exacerbate gastroesophageal reflux symptoms in infants. Avoiding citrus juices can help reduce the acidity of the stomach contents, potentially decreasing the likelihood of regurgitation.
C. Position the child with their head elevated after meals.
Position the child with their head elevated after meals: Keeping the infant in an upright position with the head elevated after meals can help prevent regurgitation by reducing the likelihood of gastric contents flowing back into the esophagus. This position facilitates gravity-assisted digestion and minimizes pressure on the lower esophageal sphincter.
D. Place the infant's head on a soft pillow while sleeping.
Place the infant's head on a soft pillow while sleeping: Placing the infant's head on a soft pillow while sleeping is not recommended as it increases the risk of suffocation and sudden infant death syndrome (SIDS). Infants should always be placed on their back to sleep in a flat, firm surface without pillows or soft bedding to reduce the risk of adverse events.
E. Administer an antiemetic to the infant.
Administer an antiemetic to the infant: Administering an antiemetic to the infant is not typically indicated for the management of gastroesophageal reflux in infants, especially as a preventive measure. Antiemetics may have potential side effects and should only be used under the guidance of a healthcare provider for specific indications.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Nursing Care Of Children Proctored Exam. Take the full exam now
Full Explanation
A. Thicken the infant's formula with cereal: Thickening the infant's formula with cereal can help reduce the likelihood of regurgitation by increasing its viscosity and promoting better gastric emptying. This can help decrease the frequency and severity of gastroesophageal reflux episodes.
B. Avoid giving the infant citrus juices: Citrus juices are acidic and can exacerbate gastroesophageal reflux symptoms in infants. Avoiding citrus juices can help reduce the acidity of the stomach contents, potentially decreasing the likelihood of regurgitation.
C. Position the child with their head elevated after meals: Keeping the infant in an upright position with the head elevated after meals can help prevent regurgitation by reducing the likelihood of gastric contents flowing back into the esophagus. This position facilitates gravity-assisted digestion and minimizes pressure on the lower esophageal sphincter.
D. Place the infant's head on a soft pillow while sleeping: Placing the infant's head on a soft pillow while sleeping is not recommended as it increases the risk of suffocation and sudden infant death syndrome (SIDS). Infants should always be placed on their back to sleep in a flat, firm surface without pillows or soft bedding to reduce the risk of adverse events.
E. Administer an antiemetic to the infant: Administering an antiemetic to the infant is not typically indicated for the management of gastroesophageal reflux in infants, especially as a preventive measure. Antiemetics may have potential side effects and should only be used under the guidance of a healthcare provider for specific indications.
Similar Questions
A nurse in a pediatric clinic is performing a history and physical for a toddler who is scheduled to receive a measles, mumps, and rubella (MMR) immunization. Which of the following findings indicate that the immunization should be withheld?
A. Temperature of 38° C (100.4° F)
Temperature of 38°C (100.4°F):A mild fever is not a contraindication for the MMR vaccine. In fact, a low-grade fever is common after immunizations and does not warrant withholding the vaccine.
B. Family history of sudden unexpected infant death (SUID)
Family history of sudden unexpected infant death (SUID): While a family history of SUID may be concerning, it is not a contraindication for administering the MMR vaccine. This history would not directly impact the safety or effectiveness of the vaccine.
C. Taking an antihistamine for seasonal allergies
Taking an antihistamine for seasonal allergies: Taking an antihistamine for seasonal allergies does not typically contraindicate the administration of the MMR vaccine. Antihistamines are generally safe to use with vaccines, and they do not interfere with the immune response to the vaccine.
D. Receiving prednisone for nephrotic syndrome
Receiving prednisone for nephrotic syndrome:Prednisone is an immunosuppressive medication. Children receiving high-dose corticosteroids (such as prednisone) should avoid live vaccines like MMR.
Full Explanation
A. Temperature of 38°C (100.4°F): A mild fever is not a contraindication for the MMR vaccine. In fact, a low-grade fever is common after immunizations and does not warrant withholding the vaccine.
B. Family history of sudden unexpected infant death (SUID): While a family history of SUID may be concerning, it is not a contraindication for administering the MMR vaccine. This history would not directly impact the safety or effectiveness of the vaccine.
C. Taking an antihistamine for seasonal allergies: Taking an antihistamine for seasonal allergies does not typically contraindicate the administration of the MMR vaccine. Antihistamines are generally safe to use with vaccines, and they do not interfere with the immune response to the vaccine.
D. Receiving prednisone for nephrotic syndrome: Prednisone is an immunosuppressive medication. Children receiving high-dose corticosteroids (such as prednisone) should avoid live vaccines like MMR
A nurse is caring for a school-age child who has metastatic osteosarcoma. The child asks the nurse, "Am I going to die?" Which of the following responses should the nurse make?
A. "What is your pain level right now?"
"What is your pain level right now?": This response doesn't directly address the child's question about mortality and may deflect the conversation away from the child's concerns. While assessing pain is important, it should not be the immediate response to a question about mortality.
B. "Your doctor will be able to answer your questions tomorrow."
"Your doctor will be able to answer your questions tomorrow.": This response delays addressing the child's concerns and may leave the child feeling anxious or unsupported in the meantime. It's important for the nurse to provide immediate support and reassurance when a child expresses fears or worries.
C. "It sounds like you are worried. Tell me what you have been told."
"It sounds like you are worried. Tell me what you have been told.": This response acknowledges the child's emotions and invites them to share their thoughts and concerns. It opens up a dialogue between the nurse and the child, allowing the nurse to provide appropriate support and information based on the child's understanding and perspective.
D. "It's natural to worry about death, but you should focus your energy on getting better."
"It's natural to worry about death, but you should focus your energy on getting better.": While this response acknowledges the child's worry, it may come across as dismissive or minimizing of the child's concerns about mortality. It's important to validate the child's emotions and offer support rather than redirecting their focus away from their worries.
Full Explanation
A. "What is your pain level right now?": This response doesn't directly address the child's question about mortality and may deflect the conversation away from the child's concerns. While assessing pain is important, it should not be the immediate response to a question about mortality.
B. "Your doctor will be able to answer your questions tomorrow.": This response delays addressing the child's concerns and may leave the child feeling anxious or unsupported in the meantime. It's important for the nurse to provide immediate support and reassurance when a child expresses fears or worries.
C. "It sounds like you are worried. Tell me what you have been told.": This response acknowledges the child's emotions and invites them to share their thoughts and concerns. It opens up a dialogue between the nurse and the child, allowing the nurse to provide appropriate support and information based on the child's understanding and perspective.
D. "It's natural to worry about death, but you should focus your energy on getting better.": While this response acknowledges the child's worry, it may come across as dismissive or minimizing of the child's concerns about mortality. It's important to validate the child's emotions and offer support rather than redirecting their focus away from their worries.
A nurse is assessing an infant who has intussusception. Which of the following manifestations should the nurse expect?
A. Polyuria
PolyuriaPolyuria, or excessive urination, is not typically associated with intussusception. This symptom is more commonly seen in conditions affecting the kidneys or urinary tract.
B. Scaphoid abdomen
Scaphoid abdomenA scaphoid abdomen refers to a concave or hollowed appearance of the abdomen, which is not typically observed in intussusception. In intussusception, abdominal distension and tenderness are more common findings.
C. Gelatinous red stool
Gelatinous red stool Gelatinous red stool, often described as "currant jelly" stool, is a classic manifestation of intussusception. It occurs due to the mixture of blood, mucus, and bowel contents.
D. Generalized edema
Generalized edemaGeneralized edema, or swelling throughout the body, is not a typical manifestation of intussusception. It is more commonly associated with conditions such as heart failure or kidney disease.
Full Explanation
A. Polyuria
Polyuria, or excessive urination, is not typically associated with intussusception. This symptom is more commonly seen in conditions affecting the kidneys or urinary tract.
B. Scaphoid abdomen
A scaphoid abdomen refers to a concave or hollowed appearance of the abdomen, which is not typically observed in intussusception. In intussusception, abdominal distension and tenderness are more common findings.
C. Gelatinous red stool
Gelatinous red stool, often described as "currant jelly" stool, is a classic manifestation of intussusception. It occurs due to the mixture of blood, mucus, and bowel contents.
D. Generalized edema
Generalized edema, or swelling throughout the body, is not a typical manifestation of intussusception. It is more commonly associated with conditions such as heart failure or kidney disease.
